Provider Demographics
NPI:1306506183
Name:MACKEY, INEZ G
Entity type:Individual
Prefix:
First Name:INEZ
Middle Name:G
Last Name:MACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14641 EDBROOKE AVE
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-1605
Mailing Address - Country:US
Mailing Address - Phone:630-697-5066
Mailing Address - Fax:
Practice Address - Street 1:396 BELLE AIRE AVE
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2010
Practice Address - Country:US
Practice Address - Phone:815-939-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017632101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health